Fraud, Waste and Abuse Training for Medicare and Medicaid ...
Fraud, Waste and Abuse Training
for Medicare and Medicaid Providers
For Use By: Licensed affiliates and subsidiaries of Magellan Health Services, Inc.
Contents and Agenda
Define Fraud, Waste, and Abuse (FWA) Identify Who Can Commit FWA Review Applicable FWA Laws and Examples Review the Whistleblower Protection Act How to Report Suspected FWA What Can You Do
? Implement a Compliance Program
Review More Examples of FWA Additional FWA Resources Compliance Attestation Statement
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Learning Objectives
By the end of the training you will be able to:
? Recognize general health care FWA ? Identify various types of health care FWA ? Identify who can commit FWA ? Identify who is responsible for combating FWA ? Understand how to report suspected health care FWA ? Understand protections available to you when reporting suspected FWA ? Recognize pertinent laws related to FWA
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Defining Fraud, Waste & Abuse
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What is Fraud?
Fraud is the intentional deception or misrepresentation that an individual knows, or should know, to be false, or does not believe to be true, and makes, knowing the deception could result in some unauthorized benefit to himself or some other person(s).
For example:
? To purposely bill for services that were never given or to bill for a service that has a higher reimbursement than the service produced.
? Misrepresenting who provided the services, altering claim forms, electronic claim records or medical documentation.
Source: CMS Glossary:
Fraud involves making false statements or misrepresentation of material facts in order to obtain some benefit or payment for which no entitlement would otherwise exist. The acts may be committed for the person's own benefit or for the benefit of another party. In order to be considered fraud, the act must be performed knowingly, willfully and intentionally.
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